NHSBT Patient Blood Management Team
Patient Blood Management (PBM) Working GroupGuidance
Terms of Reference
Purpose:
This working group will act as either a sub-group of the Hospital Transfusion Committee (HTC) or a stand alone group to oversee the development and implementation of a trust-wide Patient Blood Management (PBM) Programme. PBM places the patient at the heart of decisions made about blood transfusion: using an evidence-based, multidisciplinary approach to optimising the care of patients who might need transfusion. The PBM Programme will ensure they receive the most effective management while minimising avoidable, inappropriate and unnecessary use of blood and blood components.
The PBM working group should be formed in response to the National Blood Transfusion Committee’s (NBTC) PBM recommendations, which are endorsed by NHS England.
To facilitate the PBM Programme, champions should be identified in those clinical areas where patients might need transfusion as part of their management, who can drive PBM work forward in their area.
Membership:
There will be a core membership and the group will co-opt staff from other directorates for specific projects / aspects of the PBM programme (see organogram in appendix i).
Members of the PBM working group should, where possible be released from daily work duties to attend meetings and undertake other group activities as deemed necessary.
Quorum:
Chair (or nominated deputy), at least one other PBM Champion, one Transfusion Practitioner, and a Hospital Transfusion Laboratory representative must attend a meeting for it to be quorate.
Chair:
It is suggested that the chair should be a PBM champion who is a major user of blood (eg medicine, surgery, obstetrics, oncology, paediatrics, anaesthesia, intensive care, trauma, emergency medicine etc).
Ideally the Chair should not be a member of the Hospital Transfusion Team (i.e. Consultant Haematologist, Transfusion Practitioner or Hospital Transfusion Laboratory representative).
The PBM working group chair will attend, or arrange for a deputy to attend, every HTC meeting.
Tenure of the chair & secretary:
Suggest 3 years, and by agreement extended for a further 3 years.
Frequency of Meetings:
Four face to face meetings per year, additional meetings as required.
Working Group Remit:
The PBM working group will perform a gap analysis of current clinical practice within the trust against the NBTC PBM recommendations. This will identify areas for development and implementation of PBM initiatives, informing their work plan and objectives.
The group is tasked with examining, overseeing and developing best practice in:
-PBM related educational programmes for clinical and laboratory staff
-Patient information and consent for transfusion
-Public and patient awareness of transfusion
-Near-Patient and Laboratory testing for anaemia and haemostasis
-Use of appropriate trigger and target thresholds for blood component transfusion
-Judicious use of transfusion and ongoing monitoring of requirement
-Pre-operative Assessment and Management of Anaemia
-Intra-operative Management of blood component therapy / alternatives
-Post-operative Management
-Management of abnormal haemostasis
-Management of anaemia – medical / obstetrics
-Good practice for blood avoidance and the use of alternatives
-Audit programme of clinical and laboratory practice related to PBM
-New technologies to support PBM
-Clinical benchmarking
A report of PBM programme activities will be produced and an updated version will be part of the report submitted to the HTC.
The PBM working group will be responsible for leading the development, implementation and ongoing management of the PBM programme for the trust, in collaboration with the HTC.
The PBM working group will be empowered to attend, by representation, any clinical meeting that is deemed to have relevance to, or impact upon, the PBM programme.
The PBM working group will be empowered to draft policies/protocols relating to clinical practices deemed to be falling under the PBM programme, for ratification and escalation by the HTC.
The PBM working group will be responsible for promoting awareness and education around the PBM programme, to include presenting at medical/surgical grand rounds, board meetings, clinical audit sessions, and other meetings as deemed appropriate and relevant.
Accountability:
The PBM working group is directly accountable to the HTC which will report to the hospital risk and governance committee.
Review:
The group will review the performance and outcomes annually. These terms of reference will be reviewed at least every 3 years.
Sharing of information and resources:
All resources will be approved by the working group before use and will be subject to document control and at least 3 yearly review.
Approved resources will be made available for use by Trust staff with guidance as necessary.
PBM Working Group Reports:
-Minutes of the PBM working group meetings will be submitted to the HTC chair, no later than 2 weeks after each meeting.
-An annual plan will be submitted to the HTC and a progress report, noting objectives, timescales and measurable outcomes will be sent to the HTC chair 2 weeks prior to every HTC, or quarterly (whichever is the most frequent) and presented by the PBM working group representative at the HTC meeting.
-A PBM working group annual report will be submitted to the HTC, to be appended to the HTC annual report.
Date agreed: xxxx
Review date: xxxx
Appendix i
Membership and reporting structure of the PBM working group
Version 1Page 1June 2015